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A 56-year-old woman with diabetes mellitus was admitted to this hospital because of hyperglycemia and chest pain.

The patient had been well, with a history of diabetes mellitus for which she took oral medication, until the previous year when glucose levels became increasingly difficult to control. Approximately 6 months before this admission, vague symptoms developed, including nausea, metallic taste, headache, throat pain, chest discomfort, and "indigestion." Omeprazole, lansoprazole, and antacids were administered, with partial relief. Three weeks before admission, she was seen in the clinic for evaluation of her symptoms. The weight was 74.4 kg and the lips were dry; the vital signs and the remainder of the examination were normal. The capillary blood glucose level was 314 mg per deciliter (17.4 mmol per liter); other results are shown in Table 1. The patient was referred to the diabetes clinic.

On examination 3 days before admission, the blood pressure was 128/76 mm Hg, the pulse 100 beats per minute, the weight 73.8 kg, the height 174 cm, and the body-mass index (the weight in kilograms divided by the square of the height in meters) 24.4. The lungs were clear, there was trace edema of the legs, and pedal pulses were 2+ bilaterally. Ultrasonography of the abdomen revealed a moderately fatty liver, pancreatic atrophy, and a cyst in the right kidney. The administration of metoclopramide was begun for presumed dysmotility. On the day of admission, the patient came to the emergency department at this hospital because of persistent discomfort in the throat, chest, and epigastrium that increased when she was in a supine position, interrupted her sleep, and was associated with postprandial abdominal fullness and nausea. She reported generalized malaise for 1 week and a metallic taste in her mouth. She reported no chest pain on exertion and no dyspnea, diaphoresis, light-headedness, palpitations, vomiting, diarrhea, melena, or blood in her stool.